A recent study published by the American Psychological Association provides strong evidence for the effectiveness of psychoanalytic psychotherapy. As practitioners we know the power and effectiveness of our work. However I, for one, can feel disarmed when I’m in meetings with other, sceptical professionals who dismiss psychoanalytic work for not having an evidence base. Unfortunately, in some of my roles I’m often in such meetings.
For this reason I was pleased to read about this APA study which reviewed eight meta-analyses, comprising 160 studies of psychodynamic therapy, plus nine meta-analyses of other psychological treatments and antidepressant medications. (Meta-analyses synthesise the results of several independent pieces of research.) The study was conducted by Jonathan Shedler, PhD, of the University of Colorado Denver School of Medicine. A journal article describing the study can be found here http://www.apa.org/news/press/releases/2010/01/psychodynamic-therapy.aspx.
The author of the study often refers to ‘psychodynamic psychotherapy’, but says that he uses the terms ‘psychodynamic psychotherapy’ and ‘psychoanalytic psychotherapy’ interchangeably. The treatment approach that he describes is familiar to me as psychoanalytic psychotherapy. Despite a somewhat dismissive attitude towards more traditional psychoanalysis, the journal article is worth reading for its strong rebuttal to those who dismiss psychoanalytic psychotherapy as unproven.
The study highlights three important findings:
Psychoanalytic psychotherapy is effective
The study looks at the effectiveness of a range of interventions, using the measure of effect size, that is, the degree of change in a treated individual, compared to a control group. In such studies an effect size of 0.8 is considered to be a large effect.
A meta-analysis of psychodynamic psychotherapy that involved 1,431 patients showed an effect size of 0.97. This compares to an effect size of a typical antidepressant of 0.31 and of CBT of up to 0.68. By this reckoning, psychodynamic psychotherapy is significantly the most effective form treatment. Of course, there have been far more studies of antidepressant medication and CBT and related therapies. The field of psychodynamic or psychoanalytic psychotherapy is far less researched and so the meta-analysis of this form of treatment may be less dependable. Nonetheless, the size of the positive findings from this meta-analysis indicates that psychoanalytic psychotherapy is at least as effective as CBT or medication, if not more so.
The change process continues after psychoanalytic psychotherapy has ended
Another important finding was that the effect size increased when patients were re-evaluated nine or more months after treatment had ended. For example, in the meta-analysis quoted above, the effect size increased to 1.51 when measured some months later, an increase of 50%. This was a consistent finding across the various meta-analyses, suggesting that the therapy had instigated a process of change that continued after the therapy had ended. Again, this is not news to practitioners of psychoanalytic psychotherapy, but it’s useful to have ‘objective’ evidence.
The agents of change found in other therapies are drawn from psychoanalytic psychotherapy
Finally, the study claims that the mechanisms of change that are found in other therapies, for example CBT, are the very processes that lie at the heart of psychoanalytic psychotherapy. The study refers to several examples of research in which transcripts of therapies were analysed, therapies delivered by both psychodynamic and CBT practitioners. Regardless of which model that therapist said that they were using, a successful outcome was more likely when the therapy utilised the familiar elements of psychoanalytic work – an unstructured dialogue that linked the patient’s feelings and perceptions to past experiences, that considered unconscious material and defences, and that looked at the therapist/patient relationship. Strict adherence to a more cognitive model was a poor predictor of a successful outcome.
So overall a very interesting study that adds to a more objective evidence base for what we know from our experience – that this work is effective. I would hope that the pendulum would begin to swing back, away from such a governmental emphasis on cognitive behavioural approaches. However, I read today that the Dutch government has removed psychoanalysis from the basic health insurance package, for ‘lack of evidence’. I suspect that an economic motive played a part in this decision and will always weigh against our work in this country too.
Thanks to Crispin Balfour for drawing my attention to the study. http://www.psychotherapynz.org/